Infertility

What is infertility?

Infertility means that there is difficulty in conceiving a child. Problems can arise because of the man's reproductive system, the woman's, or a combination of both. Many infertile couples have primary infertility, which means they were never able to conceive. Some people however have secondary fertility, which means they are having trouble conceiving even though they already have children.

For a fertile couple in their twenties having regular unprotected sex, the chance of conceiving each month is only 20- 25 per cent. So how do you know when something's amiss? The answer depends on how old you are. While the age of the man is thought to play a role, the medical definition of infertility focuses on the woman. Those under 35 are advised to seek treatment for infertility if they haven't become pregnant after 12 months of regular unprotected sex. For those over 35, the threshold is six months instead of 12.

But there are degrees of infertility. The majority of infertile couples are actually sub fertile – that is, they produce eggs and sperm but have difficulty conceiving due to disorders such as hormone imbalances and problems with the reproductive tract. Cases of total infertility – where no eggs or sperm are produced – are rare.

Diagnosis

After 12 months of trying to conceive, you should consult your gynecologist for a referral to a fertility specialist. A series of tests will need to be performed on you and your partner. They will give clues to the particular cause of your infertility and ultimately a treatment plan to overcome the problem.

Firstly, the specialist will look at both your medical histories. For the woman, this includes any previous pregnancies, regularity of periods, painful periods, pelvic pain, infections, or surgery. For the man this will include whether he has fathered children previously, testicular injury, developmental problems, infections, surgery and exposure to certain environmental factors.

Physical examination will also be performed  Other test which may include:

• Blood tests. A series of tests will be performed to establish if there is a hormonal basis for your infertility that may be corrected by hormonal supplements. You may also be tested for blood group, and sexually transmitted diseases such as HIV, Hepatitis B and Hepatitis C.
• Ultrasound examination. This examination will give information on what the ovaries and uterus look like. Your doctor will look at the growth of eggs, the thickness of the lining of the uterus (if thin, it can indicate hormonal problems), the presence of fibroids or polyps on the uterus, as well as signs of endometriosis or ovarian cysts.
• Semen analysis. A semen sample from the man is required to assess the number of sperm, how well they swim (known as 'motility') and their fertilisation capacity.

 

Sono salphingography or hysterosalpingography or Surgical laparoscopy may also be used to identify blocked fallopian tubes or endometriosis.

Infertility statistics

• One in six couples are infertile. In 40 per cent of cases the problem lies exclusively with the male, 40 per cent with the female, 10 per cent with both partners, and in a further 10 per cent of cases, the cause is unknown.
• Fertility problems strike one in three women over 35.
• One in 25 males have a low sperm count, and one in 35 are sterile.

Types of Infertility

For centuries, if a couple were unable to have a baby, the problem was deemed to be with the woman. It is now known that both men and women suffer infertility problems and they are no more common in one sex than the other. Sometimes multiple factors are involved in one or both partners.
Women can suffer from disorders such as hormone imbalances, blocked fallopian tubes, endometriosis, or abnormalities of the reproductive organs. Men can experience infertility if they have problems with the number and shape of their sperm, produce antibodies against their own sperm, or have blocked spermatic cords. In some cases, the exact cause of infertility cannot be explained.
Proper diagnosis of infertility will help in selecting a treatment plan that maximizes the chance of becoming pregnant.

Male Infertility

In about one third of couples who have difficulty conceiving, male causes will be identified. The major cause of male infertility is failure to produce enough healthy sperm. This is investigated by analyzing a sample of the man's semen. A man is diagnosed as infertile if he produces too few sperm (20 million sperm per milliliter of fluid is considered the lower limit of male fertility) or his sperm may be abnormal in structure or motility (ability to move) and unable to reach or penetrate an egg.

If you and your partner are actively trying to conceive and have no results after a year, you should visit your doctor.

Different types of male infertility

There may be problems with ejaculation — either premature ejaculation or retarded ejaculation.

There may be a disorder affecting sperm production, varicoceles (varicose veins in the spermatic cord) or undescended testes.

Less common reasons include side effects of the treatment of testicular cancer, testicular damage from infections e.g. mumps or trauma or injury to the testes.

A man may have a rare genetic or hormone deficiency, which causes infertility.

A large number of patients are known to have no cause detected for their low count or motility grouped as Idiopathic Oligoastherospermia ( OAT)

Ejaculatory problem

During sexual intercourse, if ejaculation doesn't occur or not deposited enough semen into the vagina, the migration of sperm to the fallopian tubes may become increasingly difficult.

Premature ejaculation
Premature, or rapid, ejaculation is the inability of a man to control delay ejaculation until his female partner has achieved orgasm.

Premature ejaculation is thought to be quite common but may not be so premature as to prevent conception.

Low sperm count
A low sperm count can result in difficulty in conceiving. It can be caused by a number of things, for example, an injury, radiation therapy (for cancer), excessive heat such as a fever, and certain medications. Anabolic steroids, like those used by some bodybuilders to build up their muscle bulk, are known to reduce a man's sperm count.

Cigarette smoking, excess alcohol and stress can also contribute to a low sperm count.

Immotile Sperm
Sometimes the testicles produce a sufficient number of sperm, but these sperm are unable to 'swim'. They are said to be immotile. When the sperm are ejaculated into the vagina, they have to make their way to the mature egg by 'swimming' through the cervical opening, up the uterus, and into the fallopian tubes. Some sperm cannot make this journey. This may be due to a number of reasons; for example some drugs may affect a sperm's motility.

Immunological factors
Some men produce antibodies to their own sperm, which prevent the sperm from penetrating the egg. The exact cause is not known but may be due to infection or vasectomy.

Spermatic cord occlusion
The spermatic cord is the tube that transports the sperm from each testis to the penis and any blockages will cause infertility. Common causes are tuberculosis, vasectomy, infection and other sexually transmitted diseases.

How can male infertility be treated?
There are a number of methods currently available and research is ongoing. Treatment will depend on the cause identified. Medication can be used to treat hormone deficiencies or infection.

In few selected cases Surgery may be considered if the vas deferens are blocked or there are varicoceles in the spermatic cord. Insemination of sperm into your partner’s cervix or uterus may work in cases of retrograde ejaculation (ejaculation into the bladder instead of the penis), premature or delayed ejaculation, poor sperm quality or low count, and unexplained infertility. If infertility is due to a prior vasectomy, reversal may be possible.

If the count is too low then IVF ( Test Tube Baby) or ICSI is and in cases of Nil Sperm either, surgical extraction of sperm from testes is suggested or sperm banking may also be tried to provide a viable outcome.

Female Infertility

Ovulation Disorders
A delicate balance of sex hormones (oestrogen, progesterone, luteinizing hormone and follicle stimulating hormone) is needed for the timely growth and release of the egg from the ovary (ovulation).

Hormone imbalances can cause ovulation disorders in women and are the most common cause of infertility in women.

Fallopian tube damage
The fallopian tube is where fertilization takes place, after the egg is released from the ovary it is picked up by the tube and is met by sperm. Full or partial blockage of the fallopian tubes will prevent fertilization.

Damage to the fallopian tubes can be caused by inflammation as a result of viral or bacterial infections, some types of sexually transmitted diseases, or complications of surgery such as adhesions or scarring. Most common causes of tubel damage is tuberculosis in India.

Uterus and cervical disorders
Benign growths on the uterine wall, such as fibroids or polyps, can contribute to infertility as they interfere with the attachment of the embryo to the wall of the uterus.

Abnormalities in the shape of the cervix or changes in the texture of the cervical mucus can make it difficult for the sperm to move from the vagina into the uterus.

Endometriosis
Endometrial tissue normally grows only inside the uterus (womb), but sometimes it grows outside the uterus - commonly in the reproductive organs (ovaries, fallopian tubes) or on the intestines, rectum or bladder. This condition is called endometriosis. It occurs in about 10 per cent of women.

Immunological factors
The presence of antibodies to sperm in cervical mucus can cause infertility. In other cases, the mother's immune system prevents the embryo from attaching to the wall of the uterus and so causes a miscarriage.

Polycystic Ovaries
Polycystic ovaries contain lots of small cysts, making the ovary larger than normal. The condition, called polycystic Ovarian Disease (PCOD), is also associated with high levels of androgen and oestrogen. Women with PCOD have irregular periods and may not ovulate, resulting in infertility.

Ovarian failure
Ovarian failure can be a consequence of medical treatments (for ovarian tumours for instance), or the complete failure of the ovaries to develop or contain eggs in the first place (for example, Turner's Syndrome).

The treatment for ovarian tumours may involve surgical removal of all or part of the ovary. Ovarian failure can also occur as a result of treatments such as chemotherapy and pelvic radiotherapy for cancers in other body areas. These therapies destroy eggs in the ovary.

Ageing
Age is a critical factor affecting the fertility of a woman and many women today are delaying having children. Some of the common reasons include education and career demands, financial stability, second marriages and relationships, and waiting for a suitable partner.

Reproductive function declines as a woman ages, particularly after the age of 35. Women are born with a finite number of eggs, unlike men who produce sperm most of their adult life. In the years approaching menopause, there are fewer and fewer eggs left in the ovary. The quality of eggs also diminishes as a woman gets older. By the late thirties, there is an increase in chromosome abnormalities that can result in birth defects like Down's syndrome.

Ageing can also affect other reproductive organs and functions, such as the uterus, hormone production, and ovulation. There is also a higher incidence of miscarriage in women in their late thirties.

Delaying children isn't always avoidable, but infertility treatments cannot reverse the ageing process and should not be thought of as a safeguard that will ensure a pregnancy at some point in the future. The success rates of IVF for women over 35 are much lower than for younger women.

Unexplained Infertility
In approximately 10 per cent of couples, both partners may appear fine but are still unable to become pregnant. While it is easier to treat couples where the cause of infertility is obvious, couples with unexplained infertility can also be treated.